Panel Presentation APHA 09

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  • Jaime just highlight the gold… quickly!
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  • Jaime: Just pick a couple of things to highlight
  • Jaime: JUST the title of slide
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  • Jaime
  • Respondent-driven sampling (RDS), combines "snowball sampling" with a mathematical model that weights the sample to compensate for the fact that the sample was collected in a non-random way. Well-connected individuals tend to be over-sampled because many recruitment paths lead to them, so the peer recruitment upon which network-based sampling is based is anything but random. overcomes this dilemma by showing that the breadth of coverage of network-based methods can be combined with the statistical validity of standard probability sampling methods. This model is based on a synthesis and extension of two areas of mathematics, Markov chain theory and biased network theory, which were not a part of the standard tool kit of mathematical sampling theory.
  • Proportion of condom users (U) = [(P{U recruited by non-U}) * (# of non-U from estimated mean network size (EMNS))] __________________________________________________________________________________ [(P{U recruited by non-U} * (# of non-U from EMNS) + (P{non-U recruited by U}) * (# of U from EMNS)]
  • TPB elicits participation from the target community, in our case members of the Latino community affected by HV/AIDS, to better understand and characterize factors that influence behavior. The goal is to identify potentially changeable leverage points to increase HAART adherence.
  • TPB: a person’s behavior is a function of his or her intentions to perform a specific action.
  • What we know from the literature… Among PLWHA across cultures research has shown adherence to be affected by several common barriers and facilitators. Common barriers: (fear of disclosure, concomitant substance abuse, forgetfulness, suspicions of treatment, regimens that are too complicated, number of pills required, decreased quality of life, work and family responsibilities, falling asleep, and access to medication) and common facilitators (having a sense of self-worth, seeing positive effects of antiretrovirals, accepting their seropositivity, understanding the need for strict adherence, making use of reminder tools, and having a simple regimen)
  • What we know from the literature… Among developing countries lack of information about antiretroviral therapy (ART), perceived high costs for ART and stigma are also often identified at the population level Long distance from home to the health facility, lack of co-ordination across services, and limited involvement of the community in the programme planning process are additional barriers often identified at the health systems level
  • Qualitative – Patients were recruited from 2 locations – Infectious Disease Clinic, Wake Forest University School of Medicine and AIDS Care Service in Winston-Salem, NC. ID Clinic nurses sent each week’s clinic schedule to Sarah Langdon, Associate Project Manager, who identified potential participants who were Latino (per race indicated in their chart) and HIV positive (per 042 ICD-9 code, also in their chart). The data collector (Gabriela Rojas) or the APM met with each patient upon their arrival to the clinic to 1) Screen based on immigrant/non immigrant status, and if the patient qualifies, invite them to participate.  Ms. Martha Chica, AIDS Care Service would refer her clients who met the inclusion criteria (Latino, HIV+, immigrant) to the APM. The APM would refer these names/contact information to the data collector who would schedule times to conduct the interviews with the clients at AIDS Care Service. Following completion of interview, participant given an incentive of $40 and interview form/receipt maintained in locked office of APM.
  • n=28 responses
  • n=27 responses
  • Family may be an especially important referent group.
  • n = 33 responses. Eg. Bipolar disorder: nonadherence identified as an outcome of job placement and a barrier to placement
  • Enhanced communication to allay fear that ADAP may “go away” and to overcome other impediments such as scheduling.
  • Panel Presentation APHA 09

    1. 1. HIV Prevention and Treatment among Latinos in the Southeast USA: Four Studies from a Community-Based Participatory Research Partnership
    2. 2. 4 Studies, 1 Partnership <ul><li>Laying a foundation for reproductive health and HIV prevention among recent immigrant Latinas in Central NC: A CBPR approach </li></ul><ul><ul><li>Rebecca R. Cashman, MPH </li></ul></ul><ul><li>HIV risk among immigrant Latino gay men and MSM in the rural southern USA: Findings from a respondent-driven sampling study </li></ul><ul><ul><li>Thomas P. McCoy, MS </li></ul></ul><ul><li>HoMBReS-2: A small group HIV prevention intervention for heterosexual Latino men </li></ul><ul><ul><li>Scott D. Rhodes, PhD, MPH </li></ul></ul><ul><li>Applying Theory of Planned Behavior to explore HAART adherence among HIV-positive Latino immigrant: Elicitation interview results </li></ul><ul><ul><li>Aaron T. Vissman, MPH </li></ul></ul>
    3. 3. Grant Sponsors <ul><li>amfAR: The Foundation for AIDS Research </li></ul><ul><li>Centers for Disease Control and Prevention </li></ul><ul><li>National Center on Minority Health and Health Disparities </li></ul><ul><li>National Institute of Child Health and Human Development </li></ul><ul><li>National Institute of Mental Health </li></ul>
    4. 4. CBPR Defined <ul><li>An approach to research that ensures and establishes structures for equitable participation in research by community members (including those affected by the issue being studied), organizational representatives , and academic researchers to improve health and wellbeing through action, including social change </li></ul>
    5. 5. Our CBPR Partners Include: <ul><li>Adam Foundation </li></ul><ul><li>AIDS Care Service </li></ul><ul><li>Alamance Cares </li></ul><ul><li>Asociación de Mexicanos de Carolina del Norte (AMEXCAN) </li></ul><ul><li>Burlington Soccer League Association </li></ul><ul><li>Centers for Disease Control and Prevention </li></ul><ul><li>Centro Clinico </li></ul><ul><li>Center for New North Carolinians </li></ul><ul><li>Chatham, Forsyth, & Guilford County Public Health Departments </li></ul><ul><li>Chatham Social Health Council </li></ul><ul><li>Community Members </li></ul><ul><li>El Pueblo </li></ul><ul><li>Emory University CFAR, School of Public Health </li></ul><ul><li>Family Life Council </li></ul><ul><li>Forsyth Tech Community College </li></ul>
    6. 6. Our CBPR Partners Include… <ul><li>Hispanic Liaison/El Vínculo Hispano </li></ul><ul><li>La Liga Hispana de Fútbol de North Carolina </li></ul><ul><li>Maya Soccer League Association </li></ul><ul><li>Northwest Care Consortium </li></ul><ul><li>Partnership for a Drug-Free NC </li></ul><ul><li>Que Pasa </li></ul><ul><li>Sanlee Fútbol Association </li></ul><ul><li>Sara Lee Center for Women's Health, Forsyth Medical Center </li></ul><ul><li>Services for Alcohol and Substance Abuse (SASA) </li></ul><ul><li>Student Action with Farmworkers </li></ul><ul><li>Tienda Diana </li></ul><ul><li>Townsends, Inc. </li></ul><ul><li>Triad Health Project </li></ul><ul><li>UNC CFAR, School of Public Health </li></ul>
    7. 7. Setting
    8. 8. Latinos in the US <ul><li>The proportion of the US population that is Hispanic/Latino expanded considerably during the past 2 decades </li></ul><ul><ul><li>Between the 1990 and 2000 censuses, the Latino population in grew by 58% </li></ul></ul><ul><ul><li>In NC, the number of Latinos grew by 400% </li></ul></ul><ul><ul><ul><li>Giving NC the fastest-growing Latino population in the US </li></ul></ul></ul>
    9. 9. Latinos in NC <ul><ul><li>This rapid growth rate continues today with NC having the 3 rd fastest-growing Latino population in the US </li></ul></ul><ul><ul><li>Much of this growth in rural communities </li></ul></ul>
    10. 11. Latinos in NC <ul><li>Demographics differ from Latinos who traditionally immigrated to California, Arizona, Texas, or New York </li></ul><ul><ul><li>Tend to come from rural communities in southern Mexico and Central America </li></ul></ul><ul><ul><li>Have lower educational backgrounds </li></ul></ul><ul><ul><li>Are coming to communities without histories of immigration </li></ul></ul><ul><ul><li>NC Latinos tend to be younger compared to the general population </li></ul></ul><ul><ul><li>The gender ratio has become increasingly balanced, up to 45% female in 2004 </li></ul></ul>
    11. 12. Hispanics/Latinos in the US have been disproportionately affected by HIV and STDs <ul><li>Rate of HIV infection: </li></ul><ul><li>4 times higher among Hispanics/Latinos than non-Hispanic/Latino whites, 2007 </li></ul><ul><li>Rates of: Gonorrhea, chlamydia, and syphilis </li></ul><ul><li>2-4 times higher among Hispanics/Latinos than among non-Hispanic/Latino whites, 2007 </li></ul>
    12. 13. Southeast and NC <ul><li>Rates of HIV/AIDS, gonorrhea, chlamydia, and syphilis are high </li></ul><ul><li>In 2007, HIV and STD infection rates for Latinos in NC were 3 and 4 times that of non-Latino whites, respectively </li></ul>
    13. 14. HIV Prevention, Care and Treatment among Latinos <ul><li>Tend to be based in research from early epicenters </li></ul><ul><li>Need for new studies among populations reflecting current trends in the epidemic </li></ul>
    14. 15. Laying a foundation for reproductive health and HIV prevention among recent immigrant Latinas: A CBPR approach Rebecca R. Cashman, Scott D. Rhodes, Eugenia Eng, & Florence Simán
    15. 16. <ul><li>Presenter Disclosures </li></ul><ul><li>Rebecca R. Cashman </li></ul><ul><li>The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: </li></ul><ul><li>No relationships to disclose </li></ul>
    16. 17. Research Partners <ul><li>Strong partnership among providers serving Latinos in NC </li></ul><ul><li>Has focused on health promotion and disease prevention among men </li></ul><ul><li>Partners interested in focusing on women’s sexual / reproductive health needs </li></ul>
    17. 18. Background <ul><li>Partners identified need for women’s program to balance work with men </li></ul><ul><li>Need for formative research with immigrant Latinas in area of reproductive health </li></ul><ul><li>No existing curriculum seems to satisfy needs within this community </li></ul><ul><li>Need for context-specific curriculum </li></ul>
    18. 19. Study Purpose / Objectives <ul><li>Lay groundwork for creation of new sexual and reproductive health intervention for immigrant Latinas in the southeast </li></ul><ul><li>Augment existing women’s programs with a sexual and reproductive health intervention that encourages Latina women to be ‘ agents of change ’ within their social networks to share knowledge and skills </li></ul>
    19. 20. Process <ul><li>Reviewed existing interventions, curricula, and literature </li></ul><ul><li>Conducted informal interviews with Latino-serving healthcare providers in NC </li></ul><ul><li>Worked with Latina community partner to organize and implement focus groups with immigrant Latinas </li></ul><ul><li>Created intervention curriculum outline </li></ul><ul><li>Reviewed outline with health educators and other community members for feedback and revision </li></ul>
    20. 21. Findings from Literature <ul><li>Limited sexual education in family; topic </li></ul><ul><li>taboo </li></ul><ul><li>Misconceptions about reproductive health </li></ul><ul><li>system, pregnancy, contraceptives </li></ul><ul><li>High fertility, birth rates; delayed pre-natal care </li></ul><ul><li>Need for education about Pap screening, cervical cancer prevention </li></ul><ul><li>Sexual communication predictive of condom use and HIV/STI protective behaviors </li></ul><ul><li>Multiple barriers to accessing care </li></ul>
    21. 22. Intervention Recommendations from Literature Review <ul><li>Be information-oriented and include skill-building activities </li></ul><ul><li>Integrate social/cultural concepts that put women at risk and that can keep them safe </li></ul><ul><li>Increase knowledge and clarify misconceptions about contraceptive methods and pregnancy </li></ul><ul><li>Clarify personal risk for STIs, HIV/AIDS </li></ul><ul><li>Encourage women to discuss sexual health with trusted others; provide accessible information </li></ul>
    22. 23. Informal Interviews with Local Providers <ul><li>8 health care providers </li></ul><ul><li>2 meetings with Latina professional in field for curriculum guidance </li></ul><ul><li>2 meetings with Latino community health educator for curriculum guidance </li></ul>
    23. 24. Provider Recommendations <ul><li>Need for education / information about: </li></ul><ul><ul><li>Anatomy, reproductive system </li></ul></ul><ul><ul><li>Importance of routine care, gyn. visits </li></ul></ul><ul><ul><li>How to access women’s health services </li></ul></ul><ul><ul><li>Risks for STIs and HIV/AIDS transmission; protective methods </li></ul></ul><ul><ul><li>How / when pregnancy occurs; legality of abortion </li></ul></ul>
    24. 25. Provider Recommendations <ul><li>Curriculum also should address: </li></ul><ul><ul><li>Skills for condom negotiation and talking to partner about sexual health </li></ul></ul><ul><ul><li>Shame and gender roles that influence women’s comfort in talking about sexual health </li></ul></ul><ul><li>“… In order to protect her own health, she needs to learn to negotiate during sexual relationships with her partner, learn to communicate her preferences and fears, learn about her own sexual needs, her reproductive organs, and her risks as a woman.” </li></ul>
    25. 26. Focus Group Methodology <ul><li>Fall 2008 </li></ul><ul><li>Convenience sample (N=43) </li></ul><ul><li>Locations: WFUSM, YMCA, Latino church </li></ul><ul><li>Eligibility: female, self-identifying as Latina or Hispanic, ≥ 18 yrs old, providing informed consent </li></ul><ul><li>Average group: 90 minutes </li></ul><ul><li>Discussions were audiotaped with recorded verbal consent </li></ul><ul><li>Note-taker </li></ul><ul><li>Refreshments and $20.00 compensation </li></ul>
    26. 27. Excerpted Questions from Moderator’s Guide <ul><li>What does sexual and reproductive health mean to you? </li></ul><ul><li>What does it mean to you to be ‘sexually healthy’? </li></ul><ul><li>What do you do to maintain/care for your sexual and reproductive health? [Facilitators and barriers explored.] </li></ul><ul><li>With whom do you feel comfortable talking about these issues? </li></ul><ul><li>What clinic or health center do you feel comfortable going to? </li></ul><ul><li>What do you do when you have a concern about your sexual and reproductive health? </li></ul><ul><li>What are the challenges that make it difficult for you to take care of your sexual and reproductive health? </li></ul><ul><li>What sexual and reproductive health issue/topic would you like to learn more about? </li></ul><ul><li>What would be a comfortable, pleasant place for an educational program about sexual and reproductive health with a group of women? </li></ul><ul><li>What characteristics should a person have who offers an educational program about Latinas’ sexual and reproductive health? </li></ul>
    27. 28. Focus Groups with Latinas (N=43) Characteristic Mean or n (%), as appropriate Country of origin Mexico 24 (55.8) Puerto Rico 5 (11.6) El Salvador 4 (9.3) Dominican Republic 3 (7.0) Other 7 (16.3) Years in NC 7 (range 6 months-17 years) High school ed. or below 30 (69.7) Employed 26 (60.5) Living situation Living with male partner 21 (48.8) Reported partner in country of origin 1 (2.3) Single 13 (30.2) Other 8 (18.6)
    28. 29. Qualitative Themes <ul><li>Sexual and reproductive health is a priority for immigrant Latinas </li></ul><ul><li>2. Latinas value health screenings and disease and pregnancy prevention strategies </li></ul><ul><li>“ I use condoms. Because I too think I am the only one with my partner, but one never knows. I protect myself. It’s better to prevent than lament.” </li></ul>
    29. 30. Themes, continued <ul><li>3. Latinas cite a lack of available information about sexual and reproductive health </li></ul><ul><li>“ Because it seems like every month we become aware of a new disease. Do we know how to prevent it? No, because we are not equipped with that information. Information isn’t available.” </li></ul>
    30. 31. <ul><li>4. Misinformation and myths about sexual and reproductive health may be pervasive </li></ul><ul><li>“ We protect ourselves sexually because we have to have good hygiene, cleanliness, and also inform ourselves about the serious diseases that can be found sexually, even in a public bathroom.” </li></ul>Themes, continued
    31. 32. Themes, continued <ul><li>5. Multiple barriers exist that prevent immigrant Latinas from meeting sexual and reproductive health needs </li></ul><ul><li>“ I have known many women who don’t go to the doctor… their husbands don’t like for the wife to go and have another man see her.” </li></ul><ul><li>“ For many people, language is the biggest barrier. We come to a place and no matter how hard we try, there are very few interpreters who can explain what’s happening.” </li></ul><ul><li>“ For me, it’s fear of using the methods not to get pregnant… like injections and pills… that they would affect my body.” </li></ul>
    32. 33. <ul><li>6. Latinas consider communication to be key to facilitate sexual and reproductive health </li></ul><ul><li>“ There were words that we could not say at home. ‘Penis,’ that could not be mentioned at all, but let’s not do it with our children. Let’s open up more because education is what will be important.” </li></ul>Themes, continued
    33. 34. Themes, continued <ul><li>7. Latinas recommend that a sexual and reproductive health intervention include fundamental information and be broad in scope </li></ul><ul><li>“… reproductive health…to talk about pregnancy, how a baby is getting formed inside you, what do we women need so that the baby is born healthy. What will happen during labor?” </li></ul><ul><li>“… how to apply a condom…many people don’t know how to do it. You may think your husband or partner is doing it right, but you don’t know, because you let him do it…” </li></ul>
    34. 35. Identified Key Intervention Characteristics <ul><li>A sexual and reproductive health intervention for Latinas should: </li></ul><ul><ul><li>Be explicit and simple to build a firm foundation for understanding </li></ul></ul><ul><ul><li>Clarify misunderstandings about anatomy and increase accurate knowledge-base around sexual and reproductive body parts and their functions </li></ul></ul>
    35. 36. <ul><li>Outline and describe how pregnancy occurs and safe and effective contraceptive use </li></ul><ul><li>Include information on HIV and STI transmission and prevention </li></ul><ul><li>Offer skills building around condom use and negotiating condom use </li></ul>A sexual and reproductive health intervention for Latinas should:
    36. 37. <ul><li>Provide guidance on how to access available resources and what to expect during sexual and reproductive health screening visits and testing </li></ul><ul><li>Build skills among women to effectively and safely communicate with partners, peers, adult family members, providers, and children </li></ul><ul><li>Build on informal networks of Latina women </li></ul>A sexual and reproductive health intervention for Latinas should:
    37. 38. <ul><li>Be natural-helper based </li></ul><ul><li>Utilize a variety of teaching strategies </li></ul><ul><li>Take place in community locations: </li></ul><ul><ul><ul><li>Schools, churches, community centers, housing community clubhouses, health departments </li></ul></ul></ul>A sexual and reproductive health intervention for Latinas should:
    38. 39. Curriculum Modules <ul><li>Program Overview </li></ul><ul><li>Sexuality and Introduction to Sexual / Repro. Health </li></ul><ul><li>Focus on Female Reproductive Processes </li></ul><ul><li>Understanding HIV and other STIs </li></ul><ul><li>Gender and Culture </li></ul><ul><li>Asking For What You Want / Taking Care of Yourself </li></ul><ul><li>Improving Communication with Partner(s) </li></ul><ul><li>Bringing it Together </li></ul>
    39. 40. Next Steps <ul><li>Develop curriculum manual for pilot-testing </li></ul><ul><li>Incorporate more empowerment education-based activities </li></ul><ul><li>Collaborate with community partners for guidance, feedback on curriculum components </li></ul>
    40. 41. HIV risk among immigrant Latino gay men and MSM in the rural southern USA: Findings from a respondent-driven sampling study Thomas P. McCoy, Scott D. Rhodes, Aaron T. Vissman, Kenneth C. Hergenrather, Jaime Montaño, Jorge Alonzo, Mark Wolfson, Cindy Miller, & Fred Bloom
    41. 42. <ul><li>Presenter Disclosures </li></ul><ul><li>Thomas McCoy </li></ul><ul><li>The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: </li></ul><ul><li>No relationships to disclose </li></ul>
    42. 43. Special thanks to: <ul><li>Jose Alegria-Ortega </li></ul><ul><li>Doug Heckathorn, PhD </li></ul><ul><li>Cyprian Wejnert, MA </li></ul>
    43. 44. Background <ul><li>The southeastern United States has the fastest-growing Latino population in the country and carries a disproportionate HIV/AIDS disease burden. </li></ul><ul><li>Little is known about sexual risk among recently arrived Spanish-speaking immigrant Latino MSM in the rural Southeast. </li></ul><ul><li>One of the reasons little is known is that this population has been hard to reach and research. </li></ul>
    44. 45. Hard to reach because… <ul><li>No permanent address </li></ul><ul><li>No telephone number </li></ul><ul><li>Fear of participating in research due to immigration status </li></ul><ul><li>Subpopulation of Latino gay men and MSM even more hidden </li></ul>
    45. 46. HOLA: Study Background <ul><li>Our CBPR partnership collected, analyzed, and interpreted data from a quantitative assessment to better understand and characterize: </li></ul><ul><ul><li>Social and sexual networking patterns; </li></ul></ul><ul><ul><li>Behavioral, socio-cultural, and psychological correlates of HIV risk; and </li></ul></ul><ul><ul><li>Potential intervention approaches to reduce HIV exposure and transmission </li></ul></ul><ul><ul><li>among Latino gay men and MSM living in rural NC communities. </li></ul></ul>
    46. 47. Study Goals <ul><li>Collect qualitative and quantitative data on rural Latino gay men and MSM in NC </li></ul><ul><li>Prevalence: Want to know about their behaviors, HIV risk, condom use, social networks </li></ul><ul><li>Correlates: identify correlates of HIV risk </li></ul>
    47. 48. Condom Use <ul><li>Consistent condom use (e.g., 80%-100% of the time) was one of main measures </li></ul><ul><li>Spanish-speaking Latino men compared to English-speaking Latino/Non-Latino men are less likely to report: </li></ul><ul><ul><li>Using a condom at most recent intercourse </li></ul></ul><ul><ul><li>Having a personal doctor </li></ul></ul><ul><ul><li>Having health insurance </li></ul></ul>
    48. 49. Study methods: Sampling <ul><ul><li>Respondent-driven sampling (RDS) </li></ul></ul><ul><ul><li> http://www.respondentdrivensampling.org </li></ul></ul><ul><ul><li>A chain-referral method </li></ul></ul><ul><ul><ul><li>Respondents recruiting subsequent respondents </li></ul></ul></ul><ul><ul><li>Snowball sampling-like method </li></ul></ul><ul><ul><li>Attempts to produce probability sample analogs </li></ul></ul>
    49. 50. What is RDS? <ul><li>Chain-referral sampling characterized by: </li></ul><ul><li>Long referral chains </li></ul><ul><li>By asking respondents questions and tracking, RDS accounts for: </li></ul><ul><ul><ul><li>Bias in choice of seeds </li></ul></ul></ul><ul><ul><ul><li>Differences in network size </li></ul></ul></ul><ul><ul><ul><li>Differential recruiting </li></ul></ul></ul>
    50. 51. <ul><li>Four data requirements : </li></ul><ul><ul><li>Who recruited whom </li></ul></ul><ul><ul><li>Recruiters and recruits must know one another </li></ul></ul><ul><ul><li>Personal network sizes </li></ul></ul><ul><ul><li>Ration recruitment so a few cannot do all the recruiting </li></ul></ul>RDS requirements:
    51. 52. How do we get the extra RDS data? <ul><li>Thus, need to know: </li></ul><ul><ul><li>Who recruited whom? </li></ul></ul><ul><ul><li>For each, how many in the target population does the respondent know? </li></ul></ul><ul><li>Practicioners of RDS typically use physical “coupons” to track who recruited whom </li></ul><ul><li>Usually just ask the respondent about network size as a survey question (self-report) </li></ul>
    52. 53. What RDS attempts to do… <ul><li>RDS attempts to approach a “probability sampling scheme” by approximating the sampling frame as data collection occurs </li></ul><ul><ul><li>Personal network size (Degree) </li></ul></ul><ul><ul><li>Respondent's coupon # </li></ul></ul><ul><ul><li>Respondent's recruiting coupon #’s </li></ul></ul>
    53. 54. HOLA Coupon:
    54. 55. Advantages <ul><li>Accounts for biases </li></ul><ul><li>Requires little formative research and therefore sampling can begin quickly </li></ul><ul><li>Accesses persons through their naturally existing social networks </li></ul>
    55. 56. Advantages <ul><li>Recruitment is carried out by respondents at minimal cost </li></ul><ul><li>Number of additional questions is small </li></ul><ul><li>Problem of non-response bias is reduced </li></ul>
    56. 57. Current limitations <ul><li>The interview site must be readily accessible </li></ul><ul><li>Interviewers must be culturally sensitive </li></ul><ul><li>No sampling method can completely eliminate non-response bias </li></ul>
    57. 58. Current limitations <ul><li>Population members must know one another </li></ul><ul><li>Network ties must be dense </li></ul><ul><li>Motivation in population members to recruit their peers </li></ul>
    58. 59. Current limitations <ul><li>Must verify membership in the target population </li></ul><ul><li>Statistical power decreases when homophily is high </li></ul><ul><li>Statistical inference flushed out yet? </li></ul><ul><li>Received by quantitative community? </li></ul>
    59. 60. RDS: The HOLA Study <ul><li>Recruited 17 initial “seeds” who: </li></ul><ul><ul><li>Self-identified as Latino or Hispanic </li></ul></ul><ul><ul><li>At least 18 years of age </li></ul></ul><ul><ul><li>Reported MSM behavior since age 18+ </li></ul></ul><ul><ul><li>Provided informed consent </li></ul></ul><ul><li>Seeds recruited across 7 counties (range N=1-4) </li></ul><ul><li>Participants lived in rural communities </li></ul><ul><li>Population density < 1,000 per mi 2 </li></ul>
    60. 61. RDS: The HOLA Study <ul><li>17 seeds </li></ul><ul><ul><li>≤ Recruited 3 participants each </li></ul></ul><ul><ul><ul><li>Recruits then recruited ≤ 3 participants each </li></ul></ul></ul><ul><ul><ul><ul><li>And so on… </li></ul></ul></ul></ul><ul><li>Given 3 recruitment coupons </li></ul><ul><li>Participants were given $40 for their participation in the assessment </li></ul><ul><li>For each subsequent participant he recruited the recruiter was given $20 (i.e., the total possible compensation was $40-$100). </li></ul>
    61. 62. Data Management and Analysis <ul><li>Scanned data entry with data management and cleaning efforts </li></ul><ul><li>Prepped files for analysis using RDSTAT manual & videos </li></ul><ul><li>Prevalence estimation using RDSTAT; analysis using SAS </li></ul>
    62. 63. RDSAT: RDS Analysis Tool Thus, a 95% RDS CI for the population proportion with HIV testing is (57.0%, 78.4%) The point estimate is 72.9% (sample proportion is 68.1%)
    63. 64. Results <ul><li>17 seeds </li></ul><ul><li>Total of 190 participants/assessments </li></ul><ul><li>Demographics, characteristics, health behaviors observed </li></ul><ul><li>Analyses continue… </li></ul>
    64. 65. Characteristics of the HOLA study sample (N=190) Characteristic N (%) or Mean ± SD (min-max) Age (years) 25.5 ± 5.4 (18-48) Country of origin Mexico El Salvador Guatemala 149 (79.2) 3 (1.6) 3 (1.6) Self-identified gender Male Transgender Male to Female 156 (83.4) 31 (16.6) Highest education completed Less than high school diploma High school diploma Some college (no degree) 24 (13.5) 122 (68.5) 23 (12.9)
    65. 66. *n=184; **n=181 Characteristics of the HOLA study sample (N=190) Characteristic N (%) or Mean ± SD (min-max) Employment Construction Restaurant Factory Furniture manufacturing Hairstylist/barber Janitor/industrial cleaning Animal slaughtering/processing 43 (24.4) 37 (21.0) 21 (11.9) 20 (11.4) 10 (5.7) 8 (4.6) 7 (4.0) Insurance** 42 (22.3) Length of time in NC (years) 6.3 ± 3.5 (0.3 - 22.8) Acculturation Language use/Ethnic loyalty (  = .92) Media (  = .94) Ethnic social relations (  = .93) 2 ( 9.5) 2.1 ± 0.8 (1 - 3.8) 2.5 ± 0.9 (1 - 5) 2.2 ± 0.6 (1 - 3.6) Income < $30,000 150 (82.8) Lives in own house or apartment 65 (34.6)
    66. 67. Selected prevalence estimates Sexual behavior N (Unadjusted %) (95% CI) RDS weighted % (95% CI) Forced to have sex as child or adolescent 6 (3.2%) (1.5, 6.7) 0.9% (not estimable) a Age at first sex with women or men = 16 or less 80 (42.1%) (35.3, 49.2) 45.6% (42.8, 59.3) Multiple male sex partners (2+), past 3 months 124/184 (67.4%) (60.3, 73.7) 88.9% (88.3, 98.3) Inconsistent condom use with men as insertive male partner, past 3 months 50/184 (27.2%) (21.3, 34.0) 33.7% (19.9, 48.2) Inconsistent condom use with men as receptive male partner, past 3 months 51/184 (27.7%) (21.8, 34.6) 34.0% (20.8, 42.3)
    67. 68. Selected prevalence estimates Drug use N (Unadjusted %) (95% CI) RDS weighted % (95% CI) Marijuana 100 (52.6%) (45.6, 59.6) 56.0% (50.2, 65.8) Alkyl nitrates (poppers) 74 (38.9%) (32.3, 46.0) 36.1% (29.1, 45.3) Cocaine 42 (22.1%) (16.8, 28.5) 27.1% (17.2, 31.6) Non-medical use of needles 25 (13.2%) (9.1, 18.7) 13.6% (9.7, 20.3)
    68. 69. Conclusions <ul><li>Feasibility: quantitative assessment using RDS in this population is feasible </li></ul><ul><li>Prevalence: outcomes of interest were estimable, and RDS estimates while attenuated were not overly different </li></ul><ul><li>Next steps: Inference about groups… </li></ul>
    69. 70. HoMBReS-2: A small group HIV prevention intervention for heterosexual Latino men Scott D. Rhodes, Aaron T. Vissman, Kenneth C. Hergenrather, Jaime Montaño, Cindy Miller, Thomas P. McCoy, Eugenia Eng, & Ralph J. DiClemente
    70. 71. <ul><li>Presenter Disclosures </li></ul><ul><li>Scott D. Rhodes </li></ul><ul><li>The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: </li></ul><ul><li>No relationships to disclose </li></ul>
    71. 73. HoMBReS-2 <ul><ul><li>Designed to increase condom use and HIV testing among immigrant Latino men </li></ul></ul><ul><ul><li>Not lay heath advisor approach </li></ul></ul><ul><ul><li>Based on: </li></ul></ul><ul><ul><ul><li>HoMBReS intervention </li></ul></ul></ul><ul><ul><ul><ul><li>Process findings </li></ul></ul></ul></ul><ul><ul><ul><li>Social cognitive theory </li></ul></ul></ul><ul><ul><ul><li>Empowerment education </li></ul></ul></ul><ul><ul><li>Small group led by peers (companeros de salud) </li></ul></ul><ul><ul><li>Interactive and activity-based format </li></ul></ul><ul><ul><ul><li>Included 6 video scenarios to supplement </li></ul></ul></ul><ul><ul><li>Building evidence through controlled design </li></ul></ul>
    72. 74. HoMBReS-2: Priorities <ul><ul><li>Based on partnership identified priorities: </li></ul></ul><ul><ul><li>Increase awareness of the magnitude of HIV and STD infection among Latinos in the US and NC </li></ul></ul><ul><ul><li>Provide information on types of infections, modes of transmission, signs and symptoms, and local counseling, testing, care, and treatment options </li></ul></ul><ul><ul><li>Increase condom use </li></ul></ul><ul><ul><li>Change health-compromising norms of what it means to be an immigrant Latino man </li></ul></ul><ul><ul><li>Increase the use of healthcare services </li></ul></ul>
    73. 75. HoMBReS-2 Intervention Module Abbreviated Description (1) Introduction to HoMBReS-2 and sexual health Icebreaker: Participants provide Spanish slang for “condom” Enhancing understanding of HIV and STDs globally and within the US and Latino communities Facts about HIV and STDs Overview of intervention (2) Protecting ourselves Mitos y Realidades How to use a condom; Night simulator Video: Angel/Devil; Modeling the process of bringing up condom use with partner (3) How cultural norms and expectations affect our health Introduction to the influences of cultural norms and expectations on health Activity: Identifying what does it mean to be a man, Latino man, immigrant Latino man, including attitudes towards risk and health seeking behavior. Activity: Reframing health-compromising norms and expectations about being a man Video: How to access services ; Living with HIV (4) Bringing it all together What have we done, learned?
    74. 77. Angel deveil pic <ul><li>Angel / Devil Video Scene </li></ul>
    75. 79. Modeling the process of bringing up condom use with partner: Video clip
    76. 80. How to access services: Video clip
    77. 81. <ul><li>Recruited and trained 4 companeros de salud </li></ul><ul><li>Trained 142 Latino men: </li></ul><ul><ul><li>78 received HIV prevention intervention; </li></ul></ul><ul><ul><li>64 received cancer prevention intervention </li></ul></ul><ul><ul><li>No significant differences between groups </li></ul></ul>
    78. 82. Self-Reported Baseline Characteristics <ul><li>Mean age 31.5 (Range18-66) years </li></ul><ul><li>Less than high school 61% </li></ul><ul><li>Country of origin </li></ul><ul><li>Mexico 84 (59.2) </li></ul><ul><li>El Salvador 19 (13.4) </li></ul><ul><li>Guatemala 19 (13.4) </li></ul><ul><li>Honduras 7 (4.9) </li></ul><ul><li>Nicaragua 2 (1.4) </li></ul>
    79. 83. Self-Reported Baseline Characteristics <ul><li>Employment status </li></ul><ul><li>Full time 67.4% </li></ul><ul><li>Seasonal 12.8% </li></ul><ul><li>Unemployed 15.9% </li></ul><ul><li>Disabled 3.9% </li></ul><ul><li>Mean current weekly salary $315 </li></ul><ul><li>Jobs </li></ul><ul><li>Factory 23.6% </li></ul><ul><li>Construction 22.1% </li></ul><ul><li>Animal slaughter/processing 16.5% </li></ul><ul><li>Food services 7.9% </li></ul><ul><li>Lawncare / landscaping 4.7% </li></ul><ul><li>Other 22% </li></ul><ul><li>Haven’t worked in past 12 months 3.2% </li></ul>
    80. 84. Self-Reported Baseline Characteristics <ul><li>Acculturation (1-5 scale) 1.7 (Range 1-4) </li></ul><ul><li>Self-identified sexual orientation </li></ul><ul><li>Heterosexual 95.7% </li></ul><ul><li>Gay 2.2% </li></ul><ul><li>Bisexual 0.7% </li></ul><ul><li>Current relationship status </li></ul><ul><li>Single, dating 51.8% </li></ul><ul><li>Partnered, married 48.2% </li></ul><ul><li>Not monogamous 33.3% </li></ul><ul><li>Past 3-months given money, alcohol, </li></ul><ul><li> shelter to woman for sex 12.3% </li></ul>
    81. 85. Self-Reported Baseline Characteristics <ul><li>Past 3-month consistent condom use (vaginal) 25% of 121 </li></ul><ul><li>Past 3-month consistent condom use (anal-F) 38% of 55 </li></ul><ul><li>Past-year HIV testing/counseling 35% </li></ul><ul><li>Past-year STD testing/counseling 30% </li></ul>
    82. 86. Applying Theory of Planned Behavior to explore HAART adherence among HIV-positive Latino immigrants: Elicitation interview results Aaron T. Vissman, Scott D. Rhodes, Gabriela Rojas; Sarah Elizabeth Langdon, Aimee M. Wilkin, & Kenneth C. Hergenrather
    83. 87. <ul><li>Presenter Disclosures </li></ul><ul><li>Aaron T. Vissman </li></ul><ul><li>The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: </li></ul><ul><li>No relationships to disclose </li></ul>
    84. 88. TPB to explore adherence <ul><li>Step 1 </li></ul><ul><ul><li>Elicitation interviews, qualitative data </li></ul></ul><ul><li>Step 2 </li></ul><ul><ul><li>Collect quantitative data, using scales developed from Step 1 findings </li></ul></ul><ul><ul><ul><li>Attitude </li></ul></ul></ul><ul><ul><ul><li>Norm </li></ul></ul></ul><ul><ul><ul><li>Perceived control </li></ul></ul></ul>
    85. 89. The TPB
    86. 90. Step 1 goal: Elicitation interviews identifying beliefs about HAART <ul><li>Collect, analyze, and interpret qualitative exploratory data to identify salient: </li></ul><ul><ul><li>Behavioral beliefs </li></ul></ul><ul><ul><li>Normative beliefs </li></ul></ul><ul><ul><li>Control beliefs </li></ul></ul><ul><ul><li>Other factors </li></ul></ul><ul><ul><li>That may influence HAART adherence among Latinos with and at increased risk for HIV. </li></ul></ul>
    87. 91. Patient-reported barriers and facilitators from the literature <ul><li>Fear of disclosure </li></ul><ul><li>Complex regimens </li></ul><ul><li>Concomitant substance abuse </li></ul><ul><li>Forgetfulness </li></ul><ul><li>Suspicions of treatment </li></ul><ul><li>Decreased quality of life </li></ul><ul><li>Work and family responsibilities </li></ul><ul><li>Falling asleep </li></ul><ul><li>Access to medication </li></ul><ul><li>Having a sense of self-worth </li></ul><ul><li>Seeing positive effects of antiretrovirals </li></ul><ul><li>Accepting seropositivity </li></ul><ul><li>Understanding the need for strict adherence </li></ul><ul><li>Making use of reminder tools </li></ul><ul><li>Simple regimen </li></ul>
    88. 92. Barriers identified in research from developing countries <ul><li>Population level </li></ul><ul><li>Lack of information about antiretroviral therapy (ART) </li></ul><ul><li>Perceived high costs for ART </li></ul><ul><li>Stigma </li></ul><ul><li>Health systems level </li></ul><ul><li>Long distance from home to the health facility </li></ul><ul><li>Lack of coordination across services </li></ul><ul><li>Limited involvement of the community in the program planning process </li></ul>
    89. 93. Elicitation interviews to gain a better understanding of barriers and facilitators to adherence <ul><li>Open-ended items with probes </li></ul><ul><li>Demographics </li></ul><ul><li>Items “external” to TPB </li></ul><ul><li>TPB items: </li></ul><ul><ul><li>Influential referent groups </li></ul></ul><ul><ul><li>Outcomes of treatment adherence </li></ul></ul><ul><ul><li>Impediments to adherence </li></ul></ul>
    90. 94. Elicitation Interview Guide <ul><li>Demographics and background </li></ul><ul><li>Feelings and opinions about medicine in the US </li></ul><ul><li>Advantages / disadvantages of taking HIV-medicine </li></ul><ul><li>Who supports / opposes HIV-medicine adherence </li></ul><ul><li>What resources that make it easier to stay adherent </li></ul><ul><li>What is trust and what jeopardizes trust with doctors / medicine? </li></ul><ul><li>Sweeper question </li></ul>
    91. 95. Participant Recruitment <ul><ul><li>Infectious Disease Clinic, WFU-School of Medicine </li></ul></ul><ul><ul><ul><li>Screened using EMR and again at appointment </li></ul></ul></ul><ul><ul><li>AIDS Care Service, Winston-Salem </li></ul></ul><ul><ul><ul><ul><li>Screened by a case manager </li></ul></ul></ul></ul><ul><li>Interviews were conducted in Spanish </li></ul><ul><li>$40 cash incentive </li></ul>
    92. 96. Elicitation Interview Analysis <ul><li>Transcription by a native Spanish speaker </li></ul><ul><li>Coded for domains, themes, and patterns </li></ul><ul><li>Themes compared and revised by 3 researchers </li></ul><ul><li>Salient beliefs organized by cognitive determinant </li></ul><ul><ul><li>Behavioral beliefs </li></ul></ul><ul><ul><li>Normative beliefs </li></ul></ul><ul><ul><li>Control beliefs </li></ul></ul>
    93. 97. Participants (N=25) <ul><li>Sero-status and care </li></ul><ul><ul><li>HIV+, in care: 17 (68%) </li></ul></ul><ul><ul><li>HIV+, not in care: 3 (12%) </li></ul></ul><ul><ul><li>HIV-, at increased risk: 5 (20%) </li></ul></ul><ul><li>Mean age: 38.6 (Range: 25-52) years </li></ul><ul><li>Gender: Male 20 (80%); Female 5 (20%) </li></ul><ul><li>Country of origin </li></ul><ul><ul><li>Mexico 20 (80%) </li></ul></ul><ul><ul><li>El Salvador 2 (8%) </li></ul></ul><ul><ul><li>Honduras 1 (4%) </li></ul></ul><ul><ul><li>Cuba 1 (4%) </li></ul></ul><ul><ul><li>Dominican Republic 1 (4%) </li></ul></ul>
    94. 98. Behavioral Beliefs: Outcomes of Adherence <ul><li>(n= 28 belief statements) </li></ul><ul><li>I take them to feel good or to avoid feeling sick (36%) </li></ul><ul><li>I take them to extend life (21%) </li></ul><ul><li>It prevents opportunistic infection (14%) </li></ul><ul><li>To control the virus so the disease won’t get worse (11%) </li></ul><ul><li>It becomes habitual, like taking vitamins (7%) </li></ul><ul><li>Doctors know if they are prescribing the right medicine (7%) </li></ul><ul><li>Damage to the liver (4%) </li></ul>
    95. 99. Influential Referent Groups <ul><li>(n=27 belief statements) </li></ul><ul><li>Family (48%) </li></ul><ul><li>Partner/Spouse (33%) </li></ul><ul><li>Doctor (7%) </li></ul><ul><li>Friends who are HIV+ (4%) </li></ul><ul><li>Counselor (4%) </li></ul><ul><li>Support groups (4%) </li></ul>
    96. 100. Influential Referent Group: Family <ul><li>“ No one, just me. [no one knows] The truth is that I have family here, but I don’t want them to pity me… and I don’t want to cause them pain” </li></ul>
    97. 101. Control Beliefs: Impediments and Facilitators to Adherence <ul><li>(n=33 belief statements) </li></ul><ul><li>Unpleasant side effects (24%) </li></ul><ul><li>Communication with providers (18%) </li></ul><ul><li>Appointment scheduling (21%) </li></ul><ul><li>Financial cost / insurance lapse (12%) </li></ul><ul><li>Extended travel for work or to visit family (6%) </li></ul><ul><li>Fear of deportation (6%) </li></ul><ul><li>Racial discrimination (3%) </li></ul><ul><li>Depression (3%) </li></ul><ul><li>Unemployment (3%) </li></ul><ul><li>No permanent address (3%) </li></ul>
    98. 102. Impediments and Facilitators: Communication with Physician <ul><li>“ Here you get an appointment every two or three months, and I say it shouldn’t be that way. In my country, I think it’s 100% more professional.” </li></ul>
    99. 103. Next steps <ul><li>Step 2 : </li></ul><ul><li>Implement a Spanish-language quantitative assessment comprised of scales developed from Step 1 findings, </li></ul><ul><li>Analyze results to develop a model to explain HAART adherence among Latinos with HIV/AIDS. </li></ul>
    100. 104. Long-Term Intervention <ul><li>Enhance identified behavioral beliefs which are correlated with increased adherence </li></ul><ul><li>Assess referent involvement and work with those referents identified as key </li></ul><ul><li>Reduce barriers and enhance self-efficacy over identified impediments </li></ul>
    101. 105. QUESTIONS?
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